Get the free 6170 form - dhcs ca

Print Form State of California-Health and Human Services Agency Department of Health Care Services Readmission Screening and Resident Review (PARR) Level I Screening Document The federal Omnibus Reconciliation

How to fill out 6170 form - dhcs

How to fill out 6170 form - dhcs? Who needs 6170 form - dhcs?

1. The 6170 form - dhcs is used for reporting information on patients who reside in a licensed health facility or a program facility.
2. To fill out the form, start by providing the name and address of the facility or program.
3. Next, enter the facility's Medi-Cal provider number and its National Provider Identifier (NPI) number.
4. Provide the name and Social Security number of the facility's administrator or director.
5. Indicate the type of facility or program and its license number.
6. In section A, report the total number of beds and skilled nursing beds in the facility.
7. Section B requires information about rates and adjustments for skilled nursing beds.
8. In section C, provide details on staff and patient days of care for the reporting period.
9. Section D requires information on the federal Medicare-Medicaid certification number.
10. Lastly, fill out section E with the contact information of the person completing the form.
11. The 6170 form - dhcs should be submitted to the California Department of Health Care Services (DHCS).

Who needs 6170 form - dhcs?

1. Licensed health facilities such as hospitals, nursing homes, intermediate care facilities, and psychiatric health facilities are required to fill out the 6170 form - dhcs.
2. Program facilities that provide care for clients with developmental disabilities, substance abuse issues, or mental health needs also need to complete this form.
3. The form is necessary for reporting purposes and ensuring compliance with Medi-Cal and federal regulations in the state of California.

People Also Ask about 6170 form - dhcs

What does DHCS stand for?

DEPARTMENT OF HEALTH CARE SERVICES.

What are the core values of the DHCS?

Core Values: Integrity, Service, Accountability and Innovation.

How do I contact CA Dhcs?

Telephone Service Center: (800) 541-5555.

What is the key vision of CalAIM?

The goal of CalAIM is to improve outcomes for the millions of Californians covered by Medi-Cal, especially those with the most complex needs.

What is the mission vision of Dhcs?

​The mission of DHCS is to provide Californians with access to affordable, integrated, high-quality health care, including medical, dental, mental health, substance use treatment services and long-term care. Our vision is to preserve and improve the overall health and well-being of all Californians.

Who is in charge of DHCS?

​​​​About Director Michelle Baass​​ Ms. Baass leads a team of more than 4,000 individuals at DHCS.

For pdfFiller’s FAQs

What is 6170 form - dhcs?

The 6170 form is a document used by the California Department of Health Care Services (DHCS) for individuals to apply for various Medicaid programs, including Medi-Cal and other health care services. This form collects personal information, income details, tax information, and other relevant data to determine eligibility for these programs offered by the DHCS.

Who is required to file 6170 form - dhcs?

The DHCS (California Department of Health Care Services) 6170 form is required to be filed by providers who are seeking certification or renewal as a Specialty Mental Health Services (SMHS) provider. This includes California licensed mental health professionals, such as psychiatrists, psychologists, social workers, and other mental health clinicians.

What is the purpose of 6170 form - dhcs?

The purpose of Form 6170, issued by the California Department of Health Care Services (DHCS), is to collect and document information related to the coordination of benefits (COB) for Medi-Cal recipients. COB refers to the process of determining the primary payer responsible for covering the healthcare expenses of a Medi-Cal beneficiary when multiple insurance plans or programs may be involved. Form 6170 serves as a means to gather information about other insurance plans or coverage that the beneficiary may have in order to coordinate benefits appropriately and prevent incorrect payment of claims.

What information must be reported on 6170 form - dhcs?

The DHCS 6170 form is used to report information related to specialty mental health services provided by a mental health plan to the California Department of Health Care Services (DHCS). The specific information that must be reported on the form includes: 1. Provider Information: This includes the name and identification number of the mental health plan, as well as the name, address, and contact information of the provider who rendered the services. 2. Beneficiary Information: This includes the name, identification number, and date of birth of the beneficiary who received the services. 3. Service Information: This includes details about the specific service provided, such as the date of service, the type of service (e.g., individual therapy, group therapy, medication management), and the duration of the service. 4. Diagnosis Information: This includes the primary mental health diagnosis of the beneficiary, as well as any additional diagnoses that were applicable. 5. Service Authorization Information: This includes the authorization number, start date, and end date for the services provided. It also includes information about any changes or modifications to the authorization. 6. Billing Information: This includes the cost of the service provided, the units billed, and the total amount billed. 7. Payment Information: This includes details about the payment received for the services, such as the amount paid, the payment date, and the payment source. 8. Documentation Requirements: This section includes information about the required documentation for the services rendered, such as progress notes or treatment plans. It is important to note that the specific requirements may vary based on the guidelines provided by DHCS and any updates or revisions to the form. Therefore, it's advisable to refer to the most current version of the form and any associated instructions provided by DHCS.

What is the penalty for the late filing of 6170 form - dhcs?

The penalty for the late filing of form 6170 with the Department of Health Care Services (DHCS) may vary depending on the specific circumstances and the policies of the DHCS. It is recommended to contact the DHCS directly or consult their official guidelines or regulations to determine the exact penalty amount and any additional consequences for late filing.

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